Some doctors slow to diagnose abuse

Toddler had seen doctors 15 times in four months, before death by caregiver.

Alissa Guernsey’s bruises had caught the attention of her Topeka pediatrician, who would later tell investigators that he thought there might be a medical reason for her repeated injuries.

Testing did not yield answers, so the doctor called the Department of Child Services, according to an Indiana State Police case report provided to The Tribune.

Alissa Guernsey had been taken from her mother, along with two siblings, and placed in foster care with a cousin of her mother’s, LaGrange County court records show. Alissa was a little more than a year old then, in December 2008.

Not quite four months later, on March 29, 2009, the 15-month-old was pronounced dead, a coroner concluding that she suffered from blunt force trauma to her head. Her death was ruled a homicide.

Autopsy records obtained in the case revealed old and new injuries to her head and in her mouth, in addition to the bruising and broken bones. Alissa’s brain showed lesions of trauma. It was determined that her hair had not been falling out, as a doctor had noted earlier; it was pulled out.

Although Alissa’s pediatrician had repeatedly given her caregiver prescriptions for Alissa’s pain, toxicology results showed none of the opiates in the girl’s body when she died, the records say.

But when the pediatrician reported an arm injury and other history as potential abuse on March 3, 2009, the state police report says, “He noted Alissa was playing with some pets and fell. An X-ray was taken and appeared okay. (The doctor) stated there were many bruises on Alissa’s face. He stated he did not suspect abuse and while he was sitting with her another bruise appeared on her face. ... he had made arrangements for further testing and to look into the possibility of leukemia.”

On March 5, 2009, the state police report says, Alissa was examined by a doctor at Riley Hospital for Children at Indiana University Health in Indianapolis.

That doctor found no medical cause for the injuries, according to the report, which said: “He noted, ‘It is most likely that she has been subjected to banging of her head against crib while she is asleep.’”A timeline included in the state police documents, combining DCS and medical records, shows that in the brief time Alissa lived as a ward of the state with her relatives, she had been seen by medical professionals 15 times.

Who might have helped?

Alissa’s mother and her estate are plaintiffs in a lawsuit in LaGrange Circuit Court against the foster parents and DCS, claiming that DCS case managers were negligent in watching out for Alissa’s well-being. The state police records state the birth mother had repeatedly contacted case managers in the weeks before the toddler’s death, expressing her worries about Alissa’s health and that her visitations with the girl were frequently canceled.

Alissa and two of her siblings had been deemed wards of the state and removed from their mother’s home because of claims of neglect, not long after Alissa’s father had been killed in a car crash.

In an interrogatory transcript involving the lawsuit, Alissa’s birth mother contended that DCS should have paid attention to all the doctor visits.

“They did not investigate what was the cause of all of Alissa Guernsey’s bruises and injuries,” she said during questioning. “They should have taken it seriously and taken the appropriate steps to protect her.”

According to the state police report, investigators turned to Dr. Antoinette Laskey to review Alissa’s records. Laskey is a pediatrician who specializes in child abuse at Riley.

The state police report refers to Laskey’s review of Alissa’s records: “It appears she does not feel the bruising was consistent with any type of injury related to Alissa Guernsey banging her head on the crib. She also feels the arm injury is not consistent with the explanation involving the family dog. ... In generally recapping the diagnosis, it appears Alissa Guernsey’s injuries are consistent with inflicted trauma/child abuse.”

During a phone interview several weeks ago, Dr. Laskey declined to speak about the Guernsey case or any other, citing confidentiality issues.

But she said child abuse is an issue the medical community historically has treated as a social issue, rather than the medical imperative it is.

‘They may be dead in a month’

Laskey is a pediatrician board-certified in a growing subspecialty of child abuse, one of only four in Indiana, all of them at Riley, she says. Those doctors are resources for concerned physicians around the state.

The process of determining whether a child’s history of injuries fits a possible abuse diagnosis is becoming more formalized, at a time when the doctor sees more such incidents — not fewer.

“Misdiagnosing a kid can result in death,” says Laskey, who contrasts that with, “If you misdiagnose an ear infection and you’re wrong, you might cause a side effect from the medication, or, the worst-case scenario, a ruptured eardrum.”

Timeliness and emphasizing the most likely culprits are key, she says.

“Trauma, as upsetting as it is to think about the bad things that can happen to kids, is very common,” she says.

Doctors can test for leukemia or other blood disorders that might cause bruising, she says, but physicians should not wait to act on the possibility of the more dangerous cause.

“They may be dead in a month if the abuse continues,” Laskey says.

The pediatric specialist points out that some experts say child abuse cases — and deaths — are dropping, allowing some physicians to become complacent. But Laskey points to a national study released last fall in the journal Pediatrics examining “abusive head trauma” — the leading cause of child abuse deaths — which strengthened the link between a foundering economy and those head injuries.

“It’s so surprising to hear that ‘child abuse is getting better,’ ” Laskey says, “because none of us is seeing that clinically.”

Laskey points out, however, that it’s not merely a doctor’s job to be alert to the signs of potential abuse and neglect.

“It’s a difficult discussion to have as a community,” she says, pointing out that corporal punishment is still legal in all 50 states, a rarity among industrialized nations. “Nobody wants (Child Protective Services) butting in ... but then we want to cast stones when we want them to protect other children.”

Taking more precautions

At Memorial Hospital in South Bend, doctors are working to increase the rate at which they identify “at-risk” children in abuse cases, said Dr. Bunmi Okanlami, medical director for Memorial’s Pediatric Intensive Care Unit.

A child might be taken to the hospital with a legitimately accidental injury, Okanlami said, but depending on the type of injury, it’s sometimes necessary to also run a full battery of additional tests to look for older injuries or other signs of possible abuse.

In Memorial’s PICU, Okanlami sees children with all types of traumatic injuries, caused by terrible accidents as well as repeated abuse.

Certain injuries in young children generally raise red flags: for example, a fracture in a “long bone,” like the femur, of a baby less than a year old; or a skull fracture with bleeding underneath and a blot clot on the brain area, when the parents say the child fell out of bed.

“Anytime a child is injured, we have to establish with as much certainty as we can that this is accidental,” Okanlami said. “Sometimes it’s a lot clearer than others. ... It’s a matter of listening to the story and trying to see whether the story fits the injury. And if we can’t answer that for sure, then we have to refer that child to Child Protective Services.”

Dr. Bob White, who has worked in pediatrics for 31 years and is director of the Regional Newborn Program at Memorial Hospital, said doctors are required to call the hot line even if they only have a suspicion of abuse.

“They aren’t required to have firm evidence,” he said. “They are just required (to call) even if they have a suspicion, and then CPS will open the case and do more investigation.”

Seeking justice

In Alissa Guernsey’s case, a grand jury later indicted her foster mother on two felony charges of neglect of a dependent, and the woman pleaded guilty to a B felony in Alissa’s death. The woman’s husband was granted immunity.

On May 25, 2011, the foster parent was sentenced to 10 years with six years suspended. But on Aug. 11, the judge modified her sentence to the 77 days she’d served, six months of home monitoring and three years of probation.

“There is nothing that can be done to bring back the life of the dependent child victim,” Judge J. Scott VanDerbeck wrote in his order.

Tyler Sprunger, of Shipshewana, Alissa’s 24-year-old uncle, says he was appalled at his niece’s death. He led weekly protests last fall in front of the LaGrange County Courthouse.

Family members had noticed that Alissa looked “real sickly,” pale with bruises and missing hair, but they knew their relatives had charitably taken the children in, and they did not suspect abuse.

Sprunger, outraged at the evidence and the sentence modification — “I don’t know how she’s not doing life, I really don’t,” he says — has started a Facebook page called “77 days for murder” to raise awareness.

Kevin Likes, the attorney for Alissa’s mother who filed the civil lawsuit, said it’s possible that case will go to trial late this summer.

These are difficult cases to try, he acknowledges.

“I’m involved a lot with CPS and frankly think they do a good job in some difficult situations,” Likes says. “Any government agency can probably improve, but it’s like any government agency constrained by resources, budgets and time.”